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Service Date	Type of Expense	Amount Paid	Details
12-Apr-2014	Glasses	200.00
Total paid $ 200.00

Service Date	Type of Expense	Amount Paid	Amount paid by another insurance plan	Details
12-Apr-2014	Glasses	200.00	0.0
Total paid $ 200.00

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Terms, conditions & authorization

I certify that the information provided for the claim(s) being submitted is true, accurate and complete and that I, my spouse and/or my dependants have received all goods or services as claimed.

I understand and acknowledge that submission of a claim determined by Manulife to be false or misrepresented will be reported, together with any related information/documentation, to my plan sponsor. I understand and acknowledge that Manulife may refer any claims it has determined were falsely submitted to law enforcement authorities for possible prosecution. Manulife will pursue the recovery of any money that has been obtained improperly through false claim submission.

I understand that I am required to keep the original claim receipts for 12 months following the date of this online claim submission for audit purposes. These receipts could be requested at any time during this period.

Please read and agree with the terms, conditions and authorization

Terms, conditions & authorization I have read and agree with the terms, conditions and authorization

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Terms and conditions

If you accept and agree to the following Online Claim Submissions Terms and Conditions,then click the I Agree button to continue.

About these Terms and Conditions

Accepting the Online Claim Submissions Terms and Conditions applies to all claimssubmitted within the online session. An online session begins from the time youselect the option to submit a claim and ends when you exit the online claim sessionby returning to the secure website plan member welcome page.
If you submit multiple claims (for different dependents and/or different providers)within the online session, your acceptance of the Online Claim Submissions Termsand Conditions applies to all of those claims submitted.
By clicking the I Agree button you are deemed to have read, understood and agreedto all of these Terms and Conditions.

Your Responsibilities as a Plan Member

Keep your personal site identificationcodes confidential.
You are responsible for all claims submitted online using yourpersonal identification codes.
You are responsible for continuing to accept the Terms and Conditions for use of the secured website.
You are responsible for retaining original claim receipt(s) for 12 months following the date of your online claim submission(s). Manulife may requestthese receipts at anytime within the 12 month period following claim submission.
You must accept the Consent Authorization at the end of the online claims process before your claimis submitted.
Manulife Financial reserves the right to remove your access to online claim submissionwithout prior notice or explanation.
Your online claim and your coverage may be denied or terminated if you provide false,incomplete, or misleading information, and we may share information with your plansponsor without further notification to you.
Any monies or overpayments that you may owe to Manulife Financial in accordancewith the provisions of the Group Benefits plan must be repaid. Manulife Financialmay deduct such monies from your future claim payments or pursue such other lawfulremedies as we deem necessary.

Proof of Claim

Proof of claim may be required to determine eligibility or for the purposes of anaudit or investigation.
Manulife Financial may require you to provide the original claim receipt(s); andif so requested, you are responsible for producing the receipt(s) in a time periodas defined by Manulife.
If you fail to provide the receipt(s) to Manulife Financial, we reserve the rightto classify your claim as an overpayment and will deduct such monies from your futureclaim payments.
If you fail to provide the receipt(s) to Manulife Financial, we reserve the rightto remove your access to online claim submission and/or notify your plan sponsor.

Consent authorization

I certify that I, my spouse and/or my dependants of minor or major age (Dependants), have received all goods or services claimed and that the information provided for this online claim session is true and complete. I authorize Manulife Financial (Manulife) to collect, use, maintain and disclose personal information relevant to this online claim (Information) for the purposes of Group Benefits plan administration, audit and the assessment, investigation and management of this online claim (Purposes). I am authorized by my Dependants to disclose and receive their Information, for the Purposes. I authorize any person or organization with Information, including any medical and health professionals, facilities or providers, professional regulatory bodies, any employer, group plan administrator, insurer, investigative agency, and any administrators of other benefits programs to collect, use, maintain and exchange this Information with each other and with Manulife, its reinsurers and/or its service providers, for the Purposes. I agree that both my online claim and my coverage may be denied or terminated as a result of my providing false, incomplete, or misleading Information. I agree to refund any monies or overpayments that I may owe to Manulife in accordance with the provisions of the Group Benefits plan with Manulife, and I authorize Manulife to deduct such monies from my future claims. I authorize the use of my Social Insurance Number (SIN) for the purposes of identification and administration, if my SIN is used as my plan member certificate number. I agree a photocopy, facsimile or electronic version of this authorization shall be as valid as the original. I understand that Manulife's Privacy Policy and Privacy Information Package are available at www.manulife.ca/groupbenefits , or from my Plan Sponsor.

Privacy policy

Any Information provided to or collected by Manulife in accordance with this online authorization, will be kept in a Group Benefits health file. Access to your Information will be limited to:

Manulife employees, representatives, reinsurers, and service providers in the performance of their jobs;
Persons to whom you have granted access; and
Persons authorized by law.

You have the right to request access to the personal information in your file, and, where appropriate, to have any inaccurate information corrected.

Consent Authorization